Accountant Bob Senior looks at whether the new indicators in the QOF are worth chasing
The Government has again tinkered with the QOF and some of the changes will be welcomed by GPs. But the retirement of some indicators and the introduction of new ones present a challenge in terms of practices planning for this year.
In many practices, the partners will simply roll their sleeves up and carry out the work in addition to their current workload – but before they do, they need to consider if the income can be generated without increasing practice costs. This article will look at the questions practices should be asking to calculate this.
What has changed?
Because this year’s uplift was applied through an increase in the value of a QOF point (from £127.29 to £130.51), all practices should be able to benefit from the rise – including practices that are in receipt of an MPIG correction factor payment and practices that have a PMS rather than GMS contract.
The 58.5 QOF points attached to patient experience of fast access and advanced booking (PE7 & PE8) have been removed and QOF indicators worth 32 points have been retired. New clinical indicators recommended by NICE for epilepsy, learning disability and dementia (EP9, LD2 and DEM3) have been included. The upper thresholds of three QOF indicators were increased by one percentage point (CHD6, Stroke6 and DM30).
The 96.5 QOF points released will pay for new quality and productivity indicators, incentivising more effective prescribing and a reduction in hospital outpatient referrals and emergency hospital admissions.
What are you already doing?
The first step of this is to establish exactly what work is required to meet the targets, and see if any of it is required for other purposes.
Dr Nigel Watson has already given some useful advice on this for the new quality and productivity indicators,1,2 but in many cases you may currently be paid through local enhanced services or commissioning agreements to do some of the work (although that may change).
It would be worth checking with your PCO to see if they intend on continuing these payments for the remainder of this year before you start your calculations.
The new clinical indicators on epilepsy, learning disabilities and dementia are already part of NICE advice – and in some cases the work is already being done. If so, all you will have to do is tidy up the records.
For instance, EP9 deals with the new epilepsy indicator. While it uses an existing register, you now need to record those appropriate patients who have been given information and counselling about contraception, conception and pregnancy in the preceding 15 months.
That information and counselling must be by way of a face-to-face consultation, so if the advice was given then updating the records from the notes is a simple admin task – and the £391 that a typical practice might expect to earn from the three points for this may well be adequate recompense.
How much income will the new QOF points generate?
Working out what income might be earned for a particular QOF point is not straightforward, as it will be affected by the prevalence for each practice.
The quoted figure of £130.51 per point assumes average prevalence and an average list size of approximately 5,900 patients. For such a practice the potential income available from the 96.5 points that are linked to quality and productivity indicators is shown in the box below.
Don’t forget that you will have to deduct from this whatever it will cost for the peer review element for the prescribing, outpatient referrals and emergency admissions indicators. The income from the new clinical indicators will also vary, but a rough guide would be around £391 for EP9, £391 for LD2 and £782 for DEM3.
Who is going to do the work?
It is unlikely that the work required will be able to be carried out by existing staff without any increase in hours. You should also avoid using your staff’s spare time for a low reward, as you risk not having people available for more valuable income-generating activities in future.
You need to work out what would be a fair return for taking on any extra hours. The only fair way to evaluate the true ‘profit’ earned from an indicator is to calculate a commercial hourly rate that you expect to earn from each of your staff. The hourly rate needs to be enough to cover three things:
• a staff member’s total salary cost (or a notional ‘salary’ if they are a partner), made up of basic salary and any employer’s national insurance or superannuation contributions
• a proportion of the overheads of the business
• a fair profit for their efforts.
An example is a full-time nurse on a basic salary of £34,000. After adding £3,716 for employer’s national insurance and £4,760 for employer’s superannuation, the nurse’s gross salary is a cost of £42,476 per annum.
Deciding what to do about calculating a fair add-on for overheads is not simple, as GP practices receive direct reimbursements for some of their costs, such as rent and clinical waste. There are also some overheads, such as the out-of-hours opt-out costs and locum costs, that should be left out of the equation. Looking at the profile of costs seen across the country, it might be reasonable to add one-third of the gross salary cost to cover practice overheads. In the case of the nurse mentioned above, this would amount to £14,159.
Then add something for profit. Many businesses would seek to match the gross salary cost with a similar level of profit, so that would add a final £42,476 into the calculation. This would bring the total that you would expect the nurse to generate over a year to £99,111.
On an hourly basis, based on a 37.5 hour week, this is a rate of just over £50 per hour. If you need to pay a nurse for extra hours using this example, you would need to recover a minimum of £22 per hour to cover the pure salary cost – and should be aspiring to nearer £50 per hour from a commercial point of view.
This calculation is crucial. For example, the new learning disabilities indicator LD2 uses an existing register so the relevant patients can be easily identified, and offers a potential income of £391 for a typical practice. If the required blood tests have not been done, then there is work involved in getting these points – but they can be done by a nurse or an adequately trained HCA, so this might offer adequate recompense.
What is the time scale?
The key point to making the most of the QOF is that practices need to get a grip on the detailed requirements quickly.
For instance, DEM3 has six points available, so for an average practice it could generate £782. However, it requires a range of tests to be carried out and recorded within six months of diagnosis. It is therefore an indicator that practices need to grasp hold of quickly if they are not to be timed out. The quality and productivity indicators also have specified time scales that you will have to consider when planning your workload.
What about the bigger picture?
For many of the quality and productivity indicators, once you have calculated the work needed to fulfil these requirements it is quite likely that the hourly rate will be fairly unattractive as much of this work will have to be done by a GP. However, if GP commissioning does progress in anything like the form that the Government has in mind, these three areas are very likely to be high up the priority list for consortia and you will find yourself doing the work anyway. It could therefore be argued that you might as well go for it this year and at least get paid something for your efforts.
Bob Senior is chair of the Association of Independent Specialist Medical Accountants and director of medical services at RSM Tenon
Potential income from quality and productivity indicators
Conduct an internal review of prescribing followed by an external peer review, which will include an assessment of clinical cost-effectiveness – 28 points (£3,654)
Internal review followed by an external peer review of outpatient referrals to secondary care – 21 points (£2,741)
Reviewing emergency admissions and providing alternative care along new care pathways – 47.5 points (£6,199)Contraception consultation